ENS 55489

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v t e ENS Event
21:00 Sep 23, 2021
Title	Underdose of Y-90 Theraspheres
Event Description	The following information was received via email: Louisiana Department of Environmental Quality (LDEQ) was notified by the St. Tammany Parish Hospital Director of Radiology via the LDEQ Radiation Hotline at approximately 0915 CDT on September 24, 2021, concerning a medical event which took place at the licensee's facility between 1500 and 1600 CDT on September 22, 2021. According to the Director of Radiology, the patient received 366.2 Gray of the radiation dose of Y-90 TheraSpheres, instead of the prescribed radiation dose of 720 Gray, which is more than 20 percent below the prescribed dose. The facility Physicist was notified by the Director of Radiology concerning the above medical event on or about 1600 CDT on September 22, 2021. The Physicist in turn notified the hospital Radiation Safety Officer (RSO), who notified the hospital administration concerning the medical event at approximately 0955 CDT on September 23, 2021. According to the Physicist (during a conference call with LDEQ), the remaining Y-90 dose was not shunted, but remained within the TheraSphere kit. According to the Director of Radiology and the Physicist, the prescribing physician stated the patient nevertheless received an adequate therapeutic dose of Y-90. LDEQ Event Report ID No.: LA 20210008 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 55489 +/-
Where
St. Tammany Parish Hospital Covington, Louisiana (NRC Region 4)
License number:	LA-0569-L01
Organization:	Louisiana Deq
Reporting

Agreement State
Time - Person (Reporting Time:+16.8 h0.7 days <br />0.1 weeks <br />0.023 months <br />)
Opened:	James Pate 13:48 Sep 24, 2021
NRC Officer:	Thomas Herrity
Last Updated:	Sep 24, 2021
55489 - NRC Website
v • d • e

v t e Emergency Notification System
St. Tammany Parish Hospital with Agreement State
WEEKMONTHYEAR2023-12-14T06:00:00 [Table view]
[ENS list for St. Tammany Parish Hospital]

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